Patient-centeredness as algorithm

Patient-centeredness. It’s one of the aims of care put forth more than a decade ago by the Institute of Medicine in Crossing the Quality Chasm to ensure safer, high-quality care. It’s a watchword for remembering our care should be organized for the convenience of the patient, not the provider. Patient-centeredness means focusing on a patient’s needs and preferences. The concept must live in our conscious thought to ensure that it complements clinical excellence.

Nurses lead the community of caregivers embedding patient-centeredness into care delivery. But ensuring a patient-centered approach across settings and in all healthcare organizations requires a cultural evolution with unwavering commitment to embracing the patient’s and family’s voices and choices in all matters of care. It’s a process that must be owned by all, from top to bottom.

Patient-centered care excels with a mutually beneficial partnership among patients, families, and providers. Planetree, Inc. and the Picker Institute, Inc. have produced an excellent resource, Patient-Centered Care Improvement Guide. For more than 40 years, Planetree has promoted many strategies to organize care de-livery around the patient’s needs. The Picker Institute, known for its patient-satisfaction surveys, led the inclusion of patient perspective in such surveys internationally; it has also supported education, research, and awards for best practices for patient-centered care. For 20 years, the Institute for Patient- and Family-Centered Care (www.ipfcc.org) has been advancing the practices of patient- and family-centered care, as well advising policy makers, industry leaders, and patient and family leaders. Its collaborative research focuses on ways to promote patient and family engagement. Many other organizations are helping to lead the cultural transformation that will move the vision of patient-centeredness to reality.

Hardwiring patient-centeredness so it becomes a natural part of our actions is a challenge. At times, we’re complicit in eroding patient-centeredness and reverting to provider-centric care. When a nurse responds to a patient’s question for help with, “That’s not my job” (yes—it does happen), we obliterate respect for that patient. When staff restrict visiting times, we devalue family support. When a nurse scolds a patient who has forgotten to use the call light and subsequently falls when getting out of bed, we extinguish trust. Loud talking, keeping lights on 24/7, and frequent interruptions that prohibit rest show our indifference to what’s best for our patients’ healing in hospitals. Discounting the patient inconvenience of long waits to see providers or to receive home services is insensitive at best. And allowing others to violate a patient-centered approach by short-circuiting communication reflects poorly on the whole care team.

Adhering to the familiar mantra about shared decision making—”Nothing about me without me”—calls for nurses to advocate for including the patient and family throughout the care experience. In outpatient settings, nurses can lead decision making by including the patient’s or family’s input about capacity to follow up with office visits, medications, or self-care. In the hospital, vigilant nurses can add insight into patients’ needs and preferences, and ask, “Do we know if this is OK with the patient and family?”

To help providers think about putting patients and their preferences first, we can adopt algorithms—common decision-support tools that guide a set of actions for what to do next. For decades, we’ve used algorithms in advanced life support and to wean patients from ventilators—all critical events where results count. When the most critical event for a patient and family might be getting home, we owe it to them to apply the same rigor to their care and help them achieve a timely and successful outcome. The algorithm can start with: “Welcome patients and families as partners in planning and decision making.” Get patients and families to tell their stories. It rarely takes more than the simple question, “What are you expecting from your care?” or “What could we be doing to make your care better for you?” What you’ll learn guides you to the next steps,
including giving patients control, customizing their care, and ensuring safety, transparency, and cooperation among clinicians. The critical boxes in the algorithm’s action steps will state repeatedly, “Ask the patient” or “Modify based on patient preference.” Patient-centeredness as algorithm becomes the metal mesh foundation of the care we want to give and should give.

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